The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: There are various factors that can influence the survival of patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). Vascular complications from femoral cannulation are common and are potentially serious. We analyzed the impact of vascular complications on survival of patients receiving VA ECMO. METHODS: Patients supported with VA ECMO by means of femoral cannulation from October 2010 to November 2014 were enrolled in this study. Data were gathered retrospectively by reviewing our institutional database. Patients were separated into two groups depending on the presence of major vascular complications, defined as patients who required surgical intervention. We evaluated predisposing factors for vascular complications and compared survival of patients in each group. RESULTS: There were 84 patients enrolled in the study. The rates of overall ECMO survival and survival to hospital discharge were 60% and 43%, respectively. Major vascular complications requiring surgical intervention were seen in 17 (20%) patients. Ten patients (12%) had compartment syndrome requiring prophylactic fasciotomy, and 10 patients (12%) had bleeding or hematoma requiring surgical exploration. The only significant predisposing factor for vascular complications was the absence of a distal perfusion catheter (odds ratio, 14.8; p = 0.03). The rate of survival to discharge was 18% and 49% in patients with and without vascular complications, respectively (p = 0.02). Vascular complications were an independent factor of significantly worse survival in patients receiving VA ECMO by multivariate analysis (hazard ratio, 2.17; p = 0.02). CONCLUSIONS: Vascular complications negatively affect survival in patients receiving VA ECMO support by means of femoral cannulation. The utilization of a distal perfusion catheter can decrease the incidence of complications

Extracorporeal support for patients with acute respiratory distress syndrome.

Extracorporeal membrane oxygen (ECMO) has been used for many years in patients with life-threatening hypoxaemia and/or hypercarbia. While early trials demonstrated that it was associated with poor outcomes and extensive haemorrhage, the technique has evolved. It now encompasses new technologies and understanding that the lung protective mechanical ventilation it can facilitate is inextricably linked to improving outcomes for patients. The positive results from the CESAR (Conventional ventilation or ECMO for Severe Adult Respiratory failure) study and excellent outcomes in patients who suffered severe influenza A (H1N1/09) infection have established ECMO in the care of patients with severe acute respiratory distress syndrome. Controversy remains as to at what point in the clinical pathway ECMO should be employed; as a rescue therapy or more pro-actively to enable and ensure high-quality lung protective mechanical ventilation. The primary aims of this article are to discuss: 1) the types of extracorporeal support available; 2) the rationale for its use; 3) the relationship with lung protective ventilation; and 4) the current evidence for its use

Isn’t Limb as Precious as Life?

As utilisation of peripheral extra-corporeal life support (ECLS) is becoming clinical routine, its associated complications become more frequent. Distal limb perfusion in femoral cannulation remains one of the Achille’s heels in patients with peripheral ECLS. Unless detected early, limb ischemia may result in loss of limb and sometimes life. A protocol-based approach, precautions during ECLS implantation and explantation procedures and continuous monitoring of the limb during ECLS support are key elements in preventing this complication. Utilisation of a distal limb perfusion cannula helps in prevention as well as management of limb ischemia; however, it may sometimes cause more damage than help. Management and consequence of limb ischemia essentially depends on its severity at the time of detection as well as time of intervention. This chapter offers a brief review of the burden of limb ischemia, means to prevent and approaches to manage it

Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology

Extra Corporeal Membrane Oxygenation (ECMO) indications and usage has strikingly progressed over the last 20 years; it has become essential tool in the care of adults and children with severe cardiac and pulmonary dysfunction refractory to conventional management. In this article we will provide a review of ECMO development, clinical indications, patients' management, options and cannulations techniques, complications, outcomes, and the appropriate strategy of organ management while on ECMO

Extracorporeal Cardiopulmonary Resuscitation

Extracorporeal cardiopulmonary resuscitation (ECPR) is a method of resuscitation in which venoarterial (VA) extracorporeal membrane oxygenation(ECMO) is initiated during refractory cardiac arrest. ECPR promises to enhance outcomes after cardiac arrest by minimizing neurological deficits, stabilizing the patient for early reperfusion and hypothermia, and serving as a bridge to treatment or transplant. ECPR must be initiated according to structured guidelines and protocols, which are based on the patient’s age, comorbidities, code status, neurological baseline, no flow time, and low flow time. If a patient achieves return of spontaneous circulation on ECMO, the patient will receive post cardiac arrest care which includes but is not limited to therapeutic hypothermia, early reperfusion, intra-aortic balloon pump insertion, tight glycemic control, and low ventilation. While ECPR has been shown to improve outcomes, multiple complications including bleeding, infection, renal failure, limb ischemia, and stroke can result from the treatment. Nurses play a key role in monitoring these critical patients and achieving therapeutic outcomes. As ECPR is expensive, carries high risk of complications, and can not always be performed under informed consent, thus there are ethical implications. A review of the literature indicates that low flow time, age, percutaneous intervention, and sustained ventricular fibrillation are independent factors that directly impact patient outcomes. With advances in ECPR and its use in the clinical setting, it is evident that randomized control trials and uniform ECPR protocols and guidelines are essential to improve evidence base practice and patient outcomes

Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock and Cardiac Arrest

The aim of this chapter is to discuss the indication and the role of a venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the refractory cardiogenic shock and cardiac arrest